Teacher Recognition, Concern and Referral of Mental Health Problems in the Classroom

Past research has shown inequities in youths’ access to mental health prevention and intervention services by symptom type (e.g., youth with behavioral disorders are more often identified by adults and more likely to receive intervention than youth with internalizing concerns), as well as sociodemographic factors such as gender and race/ethnicity. These disparities are likely, in part, reflective of referral decisions by adults, such as teachers, who are more likely to refer youth with observable behavior disorders than less observable internalizing concerns such as anxiety disorders. Referral decisions in the Gateway Provider Model are largely influenced by teachers’ perceived need for services. Using the Gateway Provider Model, we examined teachers’ recognition, concern for, and likelihood to refer mental health problems at the clinical and at-risk levels for externalizing and internalizing concerns. Given known disparities in referral and treatment access in symptom type, we hypothesized differences in identification, concern, and referral likelihood between behavioral disorders and internalizing concerns.

We surveyed Grade K-5 teachers (n=160) regarding their knowledge, training, and experience supporting youths’ mental health and assessed their recognition of mental health problems and related help-seeking behaviors via a vignette measure. The measure has demonstrated adequate psychometric properties in prior research and includes six vignettes, including typical, at-risk and clinical descriptions of both externalizing and internalizing behavior problems.

We found teachers recognized externalizing and internalizing problems demonstrated by children at a clinical level with near perfect accuracy. However, teachers were less likely to accurately recognize early or at-risk internalizing behavior problems than at-risk externalizing concerns (Z = -7.75, p<.001, r = 0.64), less concerned for internalizing clinical and at-risk problems than externalizing clinical and at-risk concerns (Z = -7.41, p<.001, r = 0.61), and less likely to refer internalizing clinical and at-risk problems to school (Z = -2.40, p = .008, r = 0.20) and community (Z = -2.92, p = .002, r = 0.24) psychosocial services than externalizing clinical and at-risk concerns. These results suggest teacher training strategies should include specific emphasis on developing concern and awareness of negative outcomes for early internalizing behaviors, even though they may see little to no impact of such problems in the classroom. Beyond recognizing problematic behavior exists, fostering teachers’ concern for youth demonstrating early and emerging internalizing problems may be a critical step towards connecting these youths to needed care and decreasing the disparity in treatment access.